Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | T1170 | TN |
N | 152WC0802X | Optomitrist - Corneal and Contact Lenses | T1170 | TN |
N | 152WL0500X | Optomitrist - Low Vision Rehabilitation | T1170 | TN |
N | 152WP0200X | Pediatric Optomitrist | T1170 | TN |
N | 152WS0006X | Sports Vision | T1170 | TN |
N | 152WV0400X | Optomitrist - Vision Therapist | T1170 | TN |
N | 152WX0102X | Occupational Vision | T1170 | TN |
NPI | 1023087632 |
---|---|
Provider Name | Dr. Daniel Gunn Fuller |
First Address | Memphis, TN 38104-2211 |
Second Address | Memphis, TN 38104-2211 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/03/2006 |
Last Update Date | 12/07/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
001916913 | BC BS OF TN (01) | TN |
T74455 | (02) | TN |